WELSH HEALTH CIRCULAR

Transcription

1 WELSH HEALTH CIRCULAR and NATIONAL ASSEMBLY FOR WALES CIRCULAR Cynulliad Cenedlaethol Cymru NAFWC 25/2004 National Assembly for Wales WHC (2004)024 Parc Cathays / Cathays Park Issue Date: 01/04/2004 Caerdydd / Cardiff, CF10 3NQ Status: Action Title: NHS Funded Nursing Care in care homes Guidance 2004 For action by: Local Health Boards, Local Authorities and NHS Trusts Action required: See paragraphs 5-8 Sender: Peter Lawler, Community, Primary Care and Health Service Policy Directorate Mike Shanahan, Older People and Long Term Care Directorate Contact: Margaret Jenkins, Community, Primary Care and Health Service Policy Directorate Enclosures: Guidance and Appendices, including Cross Border Protocol between England and Wales Further information: See paragraph 24 for Circulars replaced. Tel: GTN: 1208 Minicom: E-bost / Assembly.info@wales.gsi.gov. uk Direct Line: Fax: E-bost / margaret.jenkins@wales.gsi.gov.uk

2 NHS FUNDED NURSING CARE IN CARE HOMES GUIDANCE: 2004 Guidance

3 PURPOSE AND SCOPE OF THIS GUIDANCE 1. This guidance is intended to assist Local Health Boards and local government to further implement Section 49 of the Health and Social Care Act, 2001, which excludes nursing care by a registered nurse from the services which can be provided by local authorities. It should be read in conjunction with the National Health Service (Nursing Care in Residential Accommodation) (Wales) Directions It advises on the NHS responsibilities for arranging care by a registered nurse for people in care homes 1 providing nursing care from 1 April Essentially, from 1 April 2004 the NHS will be responsible for paying for the care by a registered nurse of all persons who are assessed as needing that care in a care home, including those who, prior to the implementation of section 49 of the Health and Social Care Act 2001, were the responsibility of local authorities. A key aim of this guidance is to ensure that the changes in the funding arrangements for care by a registered nurse in a care home do not have a detrimental effect on the provision of care itself. 2. This guidance is directed at Local Health Boards which will be responsible for implementing the provision of NHS Funded Nursing Care from 1 April 2004, and all those who will need to work in partnership with Local Health Boards in developing arrangements, including local authority Social Services Departments, NHS Trusts, care home providers and other interested stakeholders. 3. The document is organised so that the key aspects of the guidance are outlined in the main document, with more detail being provided on certain topics in appendices. This should enable all readers to obtain an overview of the guidance, while those with particular areas of interest can obtain the further detail they require from the relevant appendix. 4. Underpinning the guidance is the view that the further implementation of NHS Funded Nursing Care provides significant opportunities to develop partnership working, including lead or joint commissioning, single payments and unified assessment processes. Local Health Boards and local authorities, together with service providers, are encouraged to make good use of these opportunities for extending a partnership approach to their responsibilities for the provision of care. Such partnership should always be characterised by respect, openness and trust between all involved. The National Assembly for Wales publications Promoting Partnerships in Care, Planning and Commissioning Guidance, and 1 The term care home when used in this document includes those establishments formerly registered as nursing homes or mental nursing homes under Part II of the Registered Homes Act 1984 which now, in accordance with the provisions of the Care Standards Act 2000, have registered as independent hospitals in accordance with section 2(3)(b) of the 2000 Act. It is only in this very narrow category of independent hospital that residents may be eligible for NHS Funded Nursing Care. Please see article 1(2) of The NHS (Nursing Care in Residential Accommodation) (Wales) Directions 2004 for full details of the premises whose residents are potentially eligible for NHS Funded Nursing Care. Guidance

4 Flexibilities for Joint Working between Health and Local Government 2 all provide further guidance on the development of partnership working. DIRECTION 5. Local Health Board Chief Executives must discuss this guidance with NHS Trust Chief Executives, local authority Directors of Social Services, care home providers, organisations or individuals representing residents and/or their carers, and other interested parties, and agree upon local arrangements for the implementation of NHS Funded Nursing Care in care homes from 1 April It is a fundamental requirement of this guidance that Local Health Boards work closely with key stakeholders, to maintain and/or develop integrated and streamlined arrangements for the commissioning, arrangement, and provision of care in care homes. The underlying principle is that the arrangement and provision of care for service users are not in any way affected negatively by the new funding regime. 7. The changes to the funding responsibilities set out here must not cause delays in making payments to care homes providing care by a registered nurse. Local Health Boards will ensure that they have arrangements in place to pay local authorities for the nursing care by a registered nurse of residents from 1 April 2004, or have put in place alternative arrangements agreed with local authorities and care home providers. 8. Implementation of NHS Funded Nursing Care provides a genuine opportunity for establishing effective joint working arrangements. The particular opportunities for joint commissioning between Health and Social Services made available by the Health Act 1999, should help to minimise any potential disruption in care provision that the changed funding arrangements might generate ( Flexibilities for Joint Working between Health and Local Government ). Similarly the unified assessment process will facilitate closer working between statutory bodies (See Creating a Unified and Fair System for Assessing and Managing Care ). Local Health Boards, NHS Trusts and local authorities are encouraged to work together in this context to maximise these opportunities, which will contribute to the future preparation and implementation of joint strategies. SUMMARY 9. The provision of NHS Funded Nursing Care derives from Section 49 of the Health and Social Care Act, 2001, which excludes nursing care by a registered nurse from the services which can be provided by local authorities. Implementation transfers this responsibility to Local Health 2 References for documents are contained in Appendix 11 Guidance

5 Boards. Section 49 was partially implemented with effect from December 2001, introducing NHS Funded Nursing Care for self-funders and those residents who paid the majority of their care costs themselves. The full implementation of Section 49 extends the scope of NHS Funded Nursing Care to cover all those persons currently assessed as requiring care by a registered nurse in care homes who were formerly the responsibility of local authorities. 10. Arrangements for implementation of NHS Funded Nursing Care provide significant opportunities for the further development of joint working, including joint commissioning of care, between the NHS and local authorities. 11. Local Health Boards must ensure that the roles and responsibilities of Care Home Co-ordinator and Lead Nurse are allocated to appropriate staff, and that arrangements are in place for all elements of the provision of NHS Funded Nursing Care, including assessment and review, appeals, disputes, information provision, contracts and payments. 12. Arrangements for assessment and review of service users will need to be put in place within the context of the developing arrangements for Creating a Unified System for Assessing and Managing Care. 13. Local Health Boards will ensure that appropriate commissioning and budgetary arrangements are in place. These will be organised in conjunction with local authorities, to minimise disruption and maximise the scope for joint commissioning. 14. In preparation for April 2004, arrangements will be made for a planned programme of assessments for eligibility for NHS Funded Nursing Care for existing residents whose care by a registered nurse will become a NHS responsibility from 1 April Care home residents should have access to the full range of specialist NHS support that is available in other care settings and to people receiving care at home. 16. It is essential to provide residents, and those considering the need to enter a care home, and their representatives where appropriate, with all the information they require to make an informed contribution to the decision as to how, and where, their needs are most appropriately met. 17. The main guidance provides an overview of all aspects of the provision of NHS Funded Nursing Care. Further detailed guidance is contained in appendices addressing: Appendix 1:Organisational arrangements; Appendix 2: Eligibility, commissioning, budget and payment arrangements for NHS Funded Nursing Care Appendix 3: Assessment and Admission to Care Homes Guidance

6 Appendix 4: Complaints Procedures Appendix 5: Definitions and Abbreviations Appendix 6: Protocol on Cross-border Issues Appendix 7: Letter to Local Authority supported residents Appendix 8: Partnership Agreements Appendix 9: Model Contract Appendix 10: Nursing Need Placement Decision Record Appendix 11: References BACKGROUND & RELATED GUIDANCE 18. In the NHS Plan for Wales the National Assembly for Wales gave a commitment to ensure equitable access to effective and appropriate healthcare, including nursing care, according to need. 19. Section 49 of the Health and Social Care Act, 2001 removed local authorities responsibility for arranging and/or providing care by a registered nurse as part of community care and paved the way for the introduction of NHS Funded Nursing Care. 20. Since December 2001, those people paying fees for care homes from their own resources ( self funders ) and those people who paid the majority of such fees themselves have been eligible for NHS Funded Nursing Care where the NHS assessed that the care of a registered nurse was required. 21. From 1 April 2004 the NHS will become responsible for funding the care by a registered nurse for all qualifying care home residents, including those previously the responsibility of local authorities. (This also includes those formerly in receipt of preserved rights.) The NHS is also responsible for paying for the care by a registered nurse for any after-care services provided under section 117(2) of the Mental Health Act 1983 in a care home. 22. Section 24 of the National Health Service Reform and Health Care Professions Act 2002 (the 2002 Act) gives effect to the National Assembly for Wales commitment to ensure joint working in the development and implementation of local strategies for health and well being. Section 24 places a duty on each local health board and each local authority to formulate and implement a Health and Well-being Strategy for the area. Arrangements for the joint commissioning of NHS Funded Nursing Care should be developed in the wider context of this strategy, and of local strategies and frameworks for different service user groups. 23. The implementation of this circular has significant implications for a range of service commissioners and providers, and the Local Health Boards will need to ensure that they are directly involved in the planning for, and implementation of, future arrangements for the provision of NHS Funded Nursing Care. Arrangements should be put in place so that all concerned are able to discuss the ongoing implementation of NHS Funded Nursing Care. This will include: Guidance

7 Care Home Co-ordinator and Lead Nurse; NHS Funded Nursing Care assessors; Local authority contracts and finance staff; Local authority social work and care management staff; Providers of care homes; Specialist nursing equipment services; Continence advice and equipment services; Primary care services Representatives of relevant user and carer groups. 24. This Circular replaces: NAW Circular 34/01 Paying for WHC Circular (2002) 129 NHS Funded Nursing Care Payment of retainers during hospital admission. NAFWC 12/2003: WHC (2003) 33: NHS Funded Nursing Care in care homes providing nursing: Supplementary Guidance This guidance needs to be implemented in the context of a wide range of related matters and guidance, including the Unified and Fair System for Assessing and Managing Care, and the new guidance and framework on continuing NHS health care which is currently being developed. Every attempt should be made to ensure an integrated and consistent approach to these related activities and procedures. 26. This guidance and the directions which will be made relate only to nursing care as defined by section 49 of the Health and Social Care Act They do not relate to any other type of care. The obligations of the NHS in relation to other types of care, and in particular for fully funded continuing NHS health care, and including other types of nursing care, remain. This guidance will need to be reviewed in the light of experience. This should be undertaken no later than 1 April ORGANISATIONAL ARRANGEMENTS 3 Co-operation 27. Local Health Boards have the lead responsibility for implementation of NHS Funded Nursing Care. Arrangements must be developed in conjunction with all key stakeholders. Linked developments 28. The procedures relating to the provision of NHS Funded Nursing Care are closely connected to those for the provision of continuing NHS health care, and the guidance relating to Creating a Unified and Fair System for 3 Further detail is contained in Appendix 1. Guidance

8 Assessing and Managing Care. All arrangements should ensure an integrated and consistent approach to these related activities and procedures. Roles and responsibilities within the Local Health Board 29. Local Health Boards should identify two (or more) persons to undertake the roles and responsibilities of Care Home Co-ordinator and Lead Nurse (for care by a registered nurse in care homes) to implement NHS Funded Nursing Care. A number of Local Health Boards may wish to co-operate in these arrangements. Required procedures 30. Local Health Boards will need to have in place procedures for : Ensuring that assessments and reviews for NHS Funded Nursing Care are carried out and fully documented; dealing with any appeals by (potential) residents against decisions made on the basis of these assessments and reviews - existing arrangements for appeals in relation to continuing NHS health care may be extended to deal with any appeals in relation to NHS Funded Nursing Care assessments or reviews; dealing with disputes between agencies arising from assessments, funding decisions and arrangements - joint arrangements will be developed with local authorities and care home providers. Relationship with continuing NHS health care 31. The NHS and local authorities both have responsibilities for arranging and funding services that meet the needs of their population, and clarity of eligibility and responsibility for funding is important. 32. The NHS responsibilities for continuing NHS health care will remain unchanged. The requirement to fund the care by a registered nurse of people in care homes will not reduce the need also to make provision for continuing NHS health care. NHS Funded Nursing Care is different from, and not a substitute for, continuing NHS health care. Local Health Boards (working closely with local authorities) need to ensure that there is alignment between NHS Funded Nursing Care and continuing NHS health care arrangements in accordance with the relevant guidance. In carrying out an assessment, the first consideration should always be the extent to which the identified needs may meet the criteria for continuing NHS health care. Where it appears that they may meet these criteria, appropriate procedures will be instigated. Information sharing 33. Guidance on sharing information for assessment and care planning purposes is contained within the document: Creating a Unified and Fair Guidance

9 System for Assessing and Managing Care. Information will also need to be shared for administrative purposes, particularly where joint commissioning and payment systems are developed. Further guidance is contained in Guidance on Protocols for Sharing Information. Wherever possible, the reasons for sharing information should be explained, and the resident s written consent to sharing information should be obtained at an early stage, and documented. Sharing of information must take into account the requirements of the Data Protection Act Advocacy 34. Access to independent advocacy for residents (and potential residents) should be available if required to ensure that their interests are represented. Advocacy is particularly important for those users who, because of their disability, may have difficulty in expressing their views and/or wish or need to have independent representatives to act on their behalf. This will include people with dementia or severe learning difficulties. Advocacy should be available, where required, during the assessment process, as well as following admission. Availability of advocacy services varies between areas, but Local Health Boards and their partners should aim to support and develop such services. Community Health Councils have a role in advice and support for individuals with concerns or complaints regarding services provided by the NHS, including those services it purchases on their behalf. CONTRACT AND BUDGETARY ARRANGEMENTS 4 Co-ordination and continuity 35. While Local Health Boards are ultimately responsible for the management of NHS budgets, including those for NHS Funded Nursing Care, opportunities for the establishment of joint arrangements, with other Local Health Boards as well as local authorities, should be maximised. The scope for developing single payment systems, as well as Lead Commissioning, in the implementation of NHS Funded Nursing Care is considerable, and could simplify the transition to the new funding regime. Local Health Boards should work with local authorities and care home providers to develop joint contractual and payment arrangements, to ensure that provision to residents is not disrupted, and that the administrative burdens as a result of the changes are kept to a minimum. Sharing administrative arrangements and budgets with other Local Health Boards may also simplify procedures for all concerned. 36. During the transition at 1 April 2004, the principle should be that the total cost of the package should be at least the same level on 1 April as it was on March Further detail is contained in Appendix 2 Guidance

10 37. Providers, local authorities and Local Health Boards will need to agree a total funding package that takes into account the NHS contribution. When making arrangements for residential care for an individual under the National Assistance Act 1948, local authorities are responsible for the remaining costs of accommodation and personal care. There should be no gap between local authority and NHS provision. Hospital admissions 38. A payment equivalent to the NHS Funded Nursing Care rate in effect will be made by the NHS to the care home to retain a resident s bed for a period (normally up to six weeks, but this may be varied to co-ordinate with local authority contractual arrangements where appropriate) during periods of hospital admission. The Local Health Board and/or the local authority, where appropriate, will make arrangements with the home manager for the latter to inform them when such admissions occur, and when the resident returns to the home. There must be mutual agreement between the local authority and the Local Health Board, in consultation with the resident and/or an appropriate representative, before the decision is made that a placement need no longer be retained, and funding withdrawn. The effect of this on delaying the resident s discharge from hospital must be taken into account. Any changes in needs following hospitalisation will be taken into account in determining any potential change in care home requirements. Death of a resident 39. A payment equivalent to the NHS Funded Nursing Care rate in effect will be made by the NHS to the care home for a period following the death of a resident. (This will normally be four days or less, but again may be coordinated with local authority contractual arrangements). The home manager will inform the Local Health Board and/or the local authority, according to local agreements, immediately on the death of a resident. Joint placements 40. Some people are placed in care homes providing care by a registered nurse under jointly funded NHS/Social Services arrangements. Nothing in this guidance changes the scope for such arrangements, other than to indicate that local authorities no longer have the power to purchase care by a registered nurse. Health and social care agencies need to ensure that this group of people s needs are assessed regularly (at least every twelve months, or as otherwise required by changes in circumstances). At this time their eligibility for NHS Funded Nursing Care and continuing NHS Health Care needs to be considered. Cross-border placements 41. A protocol agreed between the Welsh Assembly Government and the Department of Health for placements between Wales and England has Guidance

11 been issued separately, and is attached as Appendix 6. The basic principle is that the arrangements for and level of funding applicable in the destination Primary Care Trust (England) or Local Health Board (Wales) will apply. Cross boundary arrangements (within Wales) 42. NHS responsibility for funding care by a registered nurse for care home residents will be based on the usual residency rules (Regulation 2(2) and (3) of the local Health Boards (Functions) (Wales) Regulations 2003). 5 This means that the NHS Funded Nursing Care will be funded by the destination Local Health Board, where a placement is made across local authority/local Health Board boundaries. For those financially supported by local authorities, the local authority of origin will normally remain responsible for funding the accommodation and personal care. All relevant authorities will need to co-ordinate their assessment and commissioning arrangements to ensure effective and smooth placement processes. Social Security benefits 43. These arrangements for implementing NHS Funded Nursing Care will not of themselves change anyone s entitlement to Social Security benefits. Transfer of funds 44. A transfer of resources from local authorities to the NHS will cover the cost of care by a registered nurse of those currently supported financially by local authorities. The transfer is determined by the numbers receiving financial support from local authorities in care homes providing nursing. The allocation to Local Health Boards is determined by the numbers of placements in care homes providing nursing in the Local Health Board area. Local Health Boards may wish to consider pooling allocations to assist in the management of local fluctuations in demand. Allocations to Local Health Boards will be reviewed annually, to reflect changes in the demand for and supply of places in care homes providing nursing care. Level of Funding 45. The weekly payment for NHS Funded Nursing Care will be subject to review prior to 1 April 2004 and annually thereafter. 5 The relevant regulations are the Local Health Boards (Functions) (Wales) Regulations 2003 (S.I. 2003/150) as amended by the Local Health Board (Functions) (Amendment) (Wales) Regulations 2003 (S.I. 2003/816). See also s117 of the Mental Health Act Guidance

12 ASSESSMENT AND CARE MANAGEMENT PROCESSES 6 Assessments for Care by a Registered Nurse 46. NHS Funded Nursing Care will only be paid in respect of those people identified through an assessment confirming the need for care by a registered nurse. The assessment will normally be conducted by an appropriately trained registered nurse, either employed by the NHS or otherwise acceptable to the funding Local Health Board. Where appropriate, it should form part of the unified assessment process, taking into account the requirements of Creating a Unified and Fair System for Assessing and Managing Care and of the Workbook on NHS Funded Nursing Care by Registered Nurses in Wales. Prior consideration must always be give to the possibility of eligibility for continuing NHS health care. The decision on eligibility for NHS Funded Nursing Care should only be taken when it is considered that the person does not fall within the eligibility criteria for continuing NHS health care. This will be recorded on the appropriate patient record. Where necessary, in undertaking assessments and reviews, consideration will also need to be given to instigating procedures under the In Safe Hands: Protection of Vulnerable Adults in Wales guidance. 47. Assessments relating to cross-border placements will be based on the requirements of the area of origin, if that is where an assessment has been carried out. If a Local Health Board is unsure about the appropriateness of an assessment from another area for a placement in its area, it may arrange to undertake one itself. Identified nursing needs 48. The nursing needs identified during the assessment process will be clearly recorded and included in any care plans produced. For all placements supported by local authorities the relevant health and Social Services arrangements should ensure that an agreed care plan is in place. For all residents the care plan in the home will clearly indicate how the identified nursing needs are to be met. The stability of a resident s condition and the potential need for regular or frequent review should be identified where appropriate. Reviews 49. Anyone entering a care home providing nursing care on a permanent basis after 1 April 2004 should have their nursing care needs reviewed within 3 months, in conjunction with the review by the local authority where this is appropriate, and at least every 12 months thereafter, or as identified in the initial care plan. Any significant change in the well-being of a resident may trigger a request for a review of the nursing needs, from the resident, their representative, the home manager or other appropriate person. Neither the 6 Further detail is contained in Appendix 3 Guidance

13 NHS nor a local authority can refuse a reasonable request for a review or reassessment of need. Local Health Boards and local authorities should work together to ensure that reviews are efficiently and effectively coordinated. Appeals 50. If residents or their representatives, or other interested parties, have concerns relating to the assessment of, or decision on eligibility for, NHS Funded Nursing Care, they may request a review of the situation via the designated Care Home Co-ordinator. If still dissatisfied, an appeal may be made through the Local Health Board s appeals procedures. Short term nursing care 51. There may be occasions where individuals need to go into a care home with nursing for short periods of time, for example: for planned respite care; in an emergency or crisis, for instance if a carer or relative is suddenly taken ill and is unable to look after the individual; temporary placements in care homes under section 17 of the Mental Health Act 1983; those placed in a care home who are awaiting the completion of a nursing assessment of care by a registered nurse to determine the appropriateness of the placement; or for a trial period - to explore whether they would prefer to move into a care home on a permanent basis, including placements made under section 17 of the Mental Health Act (though this would not apply to permanent residents of care homes who wanted to find another home). 52. Planned short-term placements of less than 6 weeks in appropriately registered care homes will normally be supported by NHS Funded Nursing Care. This should not impinge on the joint financial arrangements developed for the provision of intermediate care, other than ensuring that local authorities are no longer purchasing nursing care. Nor should it replace the normal commissioning arrangements for rehabilitation or convalescence. Short-term placements will usually be part of a care plan resulting from the unified assessment process, which should in these circumstances include an assessment for NHS Funded Nursing Care. Funding will normally be agreed prior to placement. In emergencies, consideration may be given to earlier assessments/care plans if they are available. In such instances, Local Health Boards should fund the 7 For any patient entitled to after-care services under section 117 of the Act, placements under section 17 need to be provided free of charge. Guidance

14 placement, and arrange for an assessment for NHS Funded Nursing Care to be carried out as soon as possible, but within two weeks of the placement, particularly if it is known that the placement is likely to become permanent or to occur regularly. Where an emergency placement involves local authority funding, arrangements for NHS Funded Nursing Care funding should be developed in agreement with the local authority. Care home providers must inform Local Health Boards immediately of any emergency placements. Preparation for April Local Health Board Care Home Co-ordinators must liaise with local authorities to arrange for a planned programme of assessments for individuals whose care by a registered nurse will become a NHS responsibility from 1 April Local Health Boards, local authorities and care homes will need to agree arrangements for prioritising assessments for NHS Funded Nursing Care and commence these assessments as soon as possible. ACCESS TO NHS SERVICES 54. Care home residents should have access to the full range of specialist NHS support that is available in other care settings and to people receiving care at home. This includes access to relevant assessments, treatment and services, some of which are detailed further below. Equipment 55. A care home is required to provide as necessary the equipment for the delivery of the care it identifies in its Statement of Purpose and for which it is registered. 56. In addition the care home should be able to access equipment services available in other care settings as required by assessments. 57. Specialist equipment needs for individual use must be specified in the nursing assessment documentation. Arrangements for the provision of equipment, and any aftercare that may be necessary, should be clearly stated in the individual s care plan. 58. Equipment is also available on prescription from a GP or a prescribing nurse. Details are contained in the Drug Tariff. Continence services 59. From 1 April 2004 the NHS will fund the cost of necessary continence products for all care home residents assessed as requiring care by a registered nurse. This funding is included in NHS Funded Nursing Care Guidance

15 weekly payment to care homes. Residents should not have to pay for continence supplies for which the NHS is responsible. 60. Local Health Boards should ensure that preliminary assessments of continence needs are carried out as part of the initial assessment and any subsequent reviews. Further assessments should be carried out where the need for this is identified. Residents of care homes should also have access to professional advice about the promotion of continence. 61. Although the provision of continence supplies will be the responsibility of the home owner, they may want to work together with Local Health Boards/NHS Trusts to consider the most effective means by which care homes can access continence supplies required by residents. For example, it may be possible for care homes to access products through existing NHS supply contracts. There is also a range of continence appliances available on prescription from GPs & nurse prescribers listed in the Drug Tariff. Items supplied on prescription are subject to the usual rules (including exemptions) on prescription charges. GP services 62. All residents of care homes should be registered with a local GP so that they can access the full range of NHS services that are, and must be, free for patients. It will be in the interest of the home to ensure that their residents are appropriately registered. Some residents may wish to remain registered with a GP who provided services prior to their admission to the home. However, the GP must be local and willing to continue providing services. 63. Although a GP may not charge NHS patients directly or indirectly for the provision of general medical services, a GP may enter into arrangements to provide professional services to any body or institution, including care homes. For example, a care home may contract for the services of a doctor that the NHS does not normally provide to patients on an individual basis (such as the occupational health of the staff of the home). That is different from individual, direct patient services, for which GPs should not be charging their registered patients. The British Medical Association has published guidance for doctors on the operation of retainer fees, Provision of services to registered nursing and residential homes: Guidance for GPs, BMA, PUBLIC INFORMATION 64. The National Assembly for Wales has recently produced a revised version of the information booklet entitled NHS Funded Nursing Care in Nursing Homes What it means for you. It will be distributed to Local Health Boards for onward distribution. It will be available on the Welsh Assembly Internet Website shortly. Guidance

16 Copies are otherwise available from: Community, Primary Care and Health Service Policy Directorate Welsh Assembly Government Cathays Park Cardiff CF10 3NQ Tel: Information on NHS Funded Nursing Care will also be included in Moving into a Care Home which is currently being revised by the National Assembly for Wales. 66. It is essential to provide residents, and those considering the need to enter a care home, and their representatives where appropriate, with all the information they require to make an effective contribution to decisions on their future care arrangements. Relevant information on NHS Funded Nursing Care should be included in locally produced information (e.g. hospital discharge). Opportunities should be made available for people to discuss their options thoroughly. 67. Information provided must include details on the fees payable, and who has responsibility for their payment. There should be no confusion for residents or their representatives as to the basis of the funding of their care (e.g. NHS Funded Nursing Care, Intermediate Care, continuing NHS health care). 68. Current residents who are financially supported by local authorities should be informed of the changes in their funding arrangements from 1 April An illustrative template for such a letter is attached as Appendix 7; local versions of letters may be produced as required. Guidance

17 APPENDIX 1 ORGANISATIONAL ARRANGEMENTS Roles and responsibilities 1.1 In order to implement NHS Funded Nursing Care, Local Health Boards must ensure that the following roles and responsibilities are allocated to at least two appropriate staff. Local Health Boards may undertake this work jointly, but the responsibility for ensuring the roles and responsibilities are carried out remains with individual Local Health Boards. Care Home Co-ordinator 1.2 This is the person who should Act as the lead manager for NHS Funded Nursing Care within the Local Health Board; Manage, on behalf of the NHS, the budget for NHS Funded Nursing Care, including responsibility for agreement that the NHS Funded Nursing Care budget will fund individuals care by a registered nurse, and day-to-day budget management; Liaise with local authorities to establish joint arrangements for the commissioning of care in care homes providing nursing care. Consult and co-ordinate in respect of contract terms and payment issues; Liaise with local authorities on the provision of services and the identification of residents requiring a nursing assessment or review, scoping the work required and the resources and arrangements necessary for its achievement; Agree the arrangements for identifying nurses who will undertake the assessments and ensure that a sufficient number, as set out in the related guidance in the Workbook, receive appropriate training in assessment; Liaise with other Local Health Boards (and local authorities, where necessary) where placements are to be made, to ensure reciprocal arrangements on the availability of funding and the acceptance of assessment decisions and documentation; Ensure the necessary assessments and reviews of registered nurse requirements are undertaken, including any formal reviews that might need to be referred to an appeals panel; Guidance

18 Act as a focal point for any concerns or complaints relating to NHS Funded Nursing Care, channel complaints to and liaise appropriately with Local Health Boards, NHS Trusts, local authorities, CSIW, care homes, etc. as necessary; and Co-ordinate action on appeals. Lead nurse 1.3 The lead nurse role needs to be allocated to a separate person (i.e. not the Care Home Co-ordinator) with the following responsibilities: Provide professional nursing advice to care homes, local authorities and the Care Home Co-ordinator about the carrying out of assessments within the context of the unified assessment process and taking into account the requirements of the Workbook on NHS Funded Care by registered nurses In Wales; Monitor the quality and consistency of the assessments for registered nurse input carried out by nurses within the Local Health Board (to fulfil this role, the Lead Nurse would not normally undertake assessments in the home Local Health Board area). Appeals 1.4 Local Health Boards will need to have in place procedures for dealing with any appeals against decisions made on the basis of assessments and reviews. Arrangements for appeals in relation to continuing NHS health care may be extended to deal with any appeals in relation to NHS Funded Nursing Care assessments or reviews. Draft guidance on continuing NHS health care is currently subject to consultation; it provides further detail on how appeals panels could be constituted. The appeals procedure will be designed to enable service-users, patients and/or carers to challenge the outcome of an assessment of need. An appeal should not normally be initiated until the review process has been implemented (see Appendix 3). Where a Local Health Board determines that an individual is not eligible for NHS Funded Nursing Care, that person or their representative has the right to appeal such a determination. An appeal would not prevent an individual from seeking redress under a formal complaints mechanism, but should normally precede such action. 1.5 Where there is dispute between Local Authority, Local Health Board or provider as to the nature or extent of an individual s level of assessed need, parties may seek to use the appeals procedure to resolve any potential dispute. Where the dispute is not resolved in this way, the matter will be referred to the agreed disputes procedure. Guidance

19 Disputes 1.6 Local Health Boards will need to have in place procedures for dealing with any disputes between local authorities, Local Health Boards and care home providers. Ideally, disputes should be resolved between appropriate officers and staff, as close to the problem as possible. In the event that a dispute cannot be resolved in this way, arrangements should be established for appropriate senior managers from each organisation to jointly address the problem. Use of bodies or persons to act as mediators should be a last resort. Complaints 1.7 Residents of care homes have access to a number of complaints procedures. These are outlined further in Appendix 4. Guidance

20 APPENDIX 2 ELIGIBILITY, COMMISSIONING, BUDGET AND PAYMENT ARRANGEMENTS FOR NHS FUNDED NURSING CARE 2.1 From 1 April 2004 the NHS will become responsible for paying for the nursing care in a care home by a registered nurse for all eligible residents. The NHS will fund the care home for the registered nurse input required by individuals at a standard rate to be determined annually. Local Health Boards should be working towards integrating their commissioning arrangements with those of the local authorities. The precise arrangements for commissioning, including any joint arrangements, will vary depending on what is developed locally, taking into account the essential requirements of this guidance. Eligibility 2.2 The following groups are eligible for NHS Funded Nursing Care, normally following an appropriate assessment resulting in a positive decision on their assessed need for NHS Funded Nursing Care: Self funding residents who pay the full cost without any financial contribution from Social Services; Those placed by Social Services where Social Services pay all or a proportion of the costs of accommodation and personal care; Those placed by Social Services where Social Services currently pay the full cost of care of those people placed under Section 117(2) of the Mental Health Act NHS Funded Nursing Care may also be provided for residents waiting for an assessment to be carried out, following notification by the care home of an admission (e.g. because of an emergency admission). Any such admission which is jointly funded with a Social Services Department will necessarily be subject to local agreements on funding arrangements. Assessments should be carried out as soon as possible, and normally be completed within two weeks of admission. If the assessment subsequently indicates that care by a registered nurse is not required, then arrangements for a more appropriate placement should be made immediately. Commissioning arrangements 2.4 For the user there should be no boundaries in the provision of care, and this needs to be recognised in the development of integrated commissioning arrangements between local authorities and Local Health Guidance

21 Boards. The most straightforward approach will be for the local authority to continue to commission all aspects of care, including nursing care by a registered nurse, under the auspices of a Partnership Agreement. 2.5 Such an agreement would enable local authorities to continue to contract for the provision of nursing care by a registered nurse. A partnership arrangement would involve the contractual documentation set out in Appendix 8. Appendix 8 also includes guidance on what should go into a partnership agreement that delegates the NHS function of providing nursing care by a registered nurse to a council. 2.6 This arrangement envisages that the council will contract for the total care package. These partnership arrangements could be extended to LHBs in areas where councils have placed people out of area. If partnership agreements are not already in place, local authorities and LHBs are advised to obtain specialist legal advice as these arrangements will be specific to individual circumstances and particular services. A model contract between the council and the care home has not been produced as these should already be in place, but LHBs will need to agree the terms relating to care by a registered nurse. 2.7 Any joint arrangements must take into account the underpinning requirements in the legislation and related guidance. Guidelines for establishing partnership arrangements are included in the following documents:- The National Health Service Bodies and Local Authorities Partnership Arrangements (Wales) Regulations 2000, Statutory Instrument 2000, no. 2993, (W.193) ion/wales/wsi2000/ e.htm Health Act Flexibilities for joint working between Health and Local Government Guidance Document, National Assembly for Wales, November Health Act 1999 Increased Flexibilities Partnership Framework: A User Guide, National Assembly for Wales, May It would be advantageous for NHS Funded Nursing Care self-funders to be included in any partnership or joint contract arrangements developed by local authorities and Local Health Boards. Self-funders should be encouraged to participate in a full assessment of their needs, and to be included in local authority contract arrangements if they so wish. 2.9 Where self-funders are not included in other local authority or joint arrangements, it is essential that payments are made to care homes under contractual arrangements. A model contract between a care home Guidance

22 and a LHB is at Appendix 9. The contract should clarify responsibilities for the provision of, and payment for, services, and identify the standards of provision required (with reference to other documented standards as appropriate) While the contract for care for self-funders may be separate, local authorities and Local Health Boards may make arrangements for payments to be processed through the local authority alongside those for local authority supported residents. However, it is preferable, where possible, for LHBs to build arrangements for nursing care by a registered nurse for self-funders into their commissioning arrangements with local authorities In exceptional circumstances, such as where there are no partnership arrangements in place, or where there are intractable practical problems, a model that would secure continuity of care and at the same time minimise administrative difficulties for the NHS, councils and providers would be an agreement between the council, the care home and the LHB for care by a registered nurse. A model contract may be found on the Department of Health website at This contract only deals with the RNCC (the English equivalent of the standard rate payable under the Welsh system) and is in addition to any existing contractual arrangements that the local authority may have with care homes providing nursing care The contracts in the Appendices listed above are model contracts only and should not simply be adopted for use. Legal advice should always be taken before entering into any form of contract or partnership arrangement. Independent hospitals 2.13 Following the implementation of the Care Standards Act, some premises formerly registered as mental nursing homes under the Registered Homes Act 1984 now have to register as independent hospitals under the Care Standards Act 2000 Act by virtue of their providing residential accommodation to person or persons detained under the Mental Health Act. Local authorities are unable to enter into a contract with such hospitals. Any contract involving NHS Funded Nursing Care in these circumstances should be placed by the NHS and any council contribution should be made to the Local Health Board via a section 28(BB) transfer or under an existing partnership arrangement. Budget management 2.14 Nurses who have appropriate training will make the assessment as to whether care by a registered nurse is needed. The assessments will be submitted to the Local Health Board Care Home Co-ordinator. The Care Home Co-ordinator will be responsible for agreeing that the NHS Funded Guidance

23 Nursing Care budget will pay for the care by a registered nurse. Where the placement is to be made in the area of another Local Health Board, the assessment will be forwarded to the co-ordinator in that Local Health Board, which will be responsible for the funding Decisions on eligibility for NHS Funded Nursing Care will be clearly documented and justified, and signed by the assessing nurse on appropriate documentation. An illustrative model form for this purpose is attached as Appendix 10. (See also 3.27) Documents used should be acceptable across Local Health Boards, so that there is no requirement for additional assessments if the resident chooses to live in a care home in an area other than their area of origin The Care Home Co-ordinator will agree funding for nursing care in a suitable home, and arrange payment according to agreed local procedures. Arrangements for funding placements will need to be jointly agreed between local authorities and Local Health Boards prior to admission where both are making a contribution Local authorities must inform Local Health Boards immediately of any change in the financial status of the resident (e.g. if they become selffunders after a period of property disregard, or if they become the responsibility of the local authority because of reducing capital). Any necessary changes to their contractual status should be implemented immediately. Local authority arrangements for deferring payments will take into account the LHB responsibility for NHS Funded Nursing Care For residents receiving financial support from local authorities, there must be mutual agreement between the local authority and the LHB before the decision is made that a placement is no longer required, and funding withdrawn. Such decisions will, of course, be made in consultation with the resident, their family or other representative, and the service provider, as appropriate. Arrangements for Payments 2.19 Systems will need to be established to pay care homes for local authority supported residents NHS Funded Nursing Care from 1 April Local Health Boards must make sure that arrangements are in place for appropriate payments from 1 April 2004 to ensure that payments are made to care homes for all eligible residents. Any interim financial burdens created whilst the required processes are being set up will need to be met by the Local Health Board and local authority as necessary, and not the provider Local Health Boards should work with local authorities and care home providers to ensure that they have streamlined payment systems in place. Payments to the care provider should come from a single source wherever possible. Single payment systems would be particularly effective where lead or joint commissioning arrangements are in place. Guidance